Provider Demographics
NPI:1376798678
Name:CMC-NORTHEAST, INC.
Entity Type:Organization
Organization Name:CMC-NORTHEAST, INC.
Other - Org Name:PAVILION PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER, OUTPATIENT PHARMACY SERVIC
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:FRASURE
Authorized Official - Suffix:III
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:704-403-2079
Mailing Address - Street 1:920 CHURCH ST N
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 CHURCH ST N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2927
Practice Address - Country:US
Practice Address - Phone:704-403-2079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC098223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1376579052OtherNPI
NCFP0600329OtherDEA